Wednesday, January 26, 2011

Health - F.D.A and Dairy Industry Spar Over Testing of Milk

Health - F.D.A and Dairy Industry Spar Over Testing of Milk

F.D.A and Dairy Industry Spar Over Testing of Milk

Posted: 26 Jan 2011 08:44 AM PST

Each year, federal inspectors find illegal levels of antibiotics in hundreds of older dairy cows bound for the slaughterhouse. Concerned that those antibiotics might also be contaminating the milk Americans drink, the Food and Drug Administration intended to begin tests this month on the milk from farms that had repeatedly sold cows tainted by drug residue.

But the testing plan met with fierce protest from the dairy industry, which said that it could force farmers to needlessly dump millions of gallons of milk while they waited for test results. Industry officials and state regulators said the testing program was poorly conceived and could lead to costly recalls that could be avoided with a better plan for testing.

In response, the F.D.A. postponed the testing, and now the two sides are sparring over how much danger the antibiotics pose and the best way to ensure that the drugs do not end up in the milk supply.

“What has been served up, up to this point, by Food and Drug has been potentially very damaging to innocent dairy farmers,” said John J. Wilson, a senior vice president for Dairy Farmers of America, the nation’s largest dairy cooperative. He said that that the nation’s milk was safe and that there was little reason to think that the slaughterhouse findings would be replicated in tests of the milk supply.

But food safety advocates said that the F.D.A.’s preliminary findings raised issues about the possible overuse of antibiotics in livestock, which many fear could undermine the effectiveness of drugs to combat human illnesses.

“Consumers certainly don’t want to be taking small amounts of drugs every time they drink milk,” said Caroline Smith DeWaal, food safety director of the Center for Science in the Public Interest, an advocacy group. “They want products that are appropriately managed to ensure those drug residues aren’t there, and the dairy farmer is the one who can control that.”

The F.D.A. said that it would confer with the industry before deciding how to proceed. “The agency remains committed to gathering the information necessary to address its concern with respect to this important potential public health issue,” it said in a statement.

The concerns of federal regulators stem from tests done by the Department of Agriculture on dairy cows sent to be slaughtered at meat plants. For years, those tests have found a small but persistent number of animals with drug residues, mostly antibiotics, that violate legal limits.

The tests found 788 dairy cows with residue violations in 2008, the most recent year for which data was available. That was a tiny fraction of the 2.6 million dairy cows slaughtered that year, but regulators say the violations are warning signs because the problem persists from year to year and some of the drugs detected are not approved for use in dairy cows.

The question for the F.D.A. is whether cows that are producing milk also have improper levels of such drugs in their bodies and whether traces of those drugs are getting into the milk.

Regulators and veterinarians say that high levels of drugs can persist in an animal’s system because of misuse of medicines on the farm.

That can include exceeding the prescribed dose or injecting a drug into muscle instead of a vein. Problems can also occur if farmers do not follow rules that require them to wait for a specified number of days after administering medication before sending an animal to slaughter or putting it into milk production.

“F.D.A. is concerned that the same poor management practices which led to the meat residues may also result in drug residues in milk,” the agency said in a document explaining its plan to the industry. In the same document, the F.D.A. said it believed that the nation’s milk supply was safe.

Today, every truckload of milk is tested for four to six antibiotics that are commonly used on dairy farms. The list includes drugs like penicillin and ampicillin, which are also prescribed for people. Each year, only a small number of truckloads are found to be “hot milk,” containing trace amounts of antibiotics. In those cases, the milk is destroyed.

But dairy farmers use many more drugs that are not regularly tested for in milk. Regulators are concerned because some of those other drugs have been showing up in the slaughterhouse testing.

Federal officials have discussed expanded testing for years. But industry executives said that it was not until last month that the F.D.A. told them it was finally going to begin.

The agency said that it planned to test milk from about 900 dairy farms that had repeatedly been caught sending cows to slaughter with illegal levels of drugs in their systems.

It said it would test for about two dozen antibiotics beyond the six that are typically tested for. The testing would also look for a painkiller and anti-inflammatory drug popular on dairy farms, called flunixin, which often shows up in the slaughterhouse testing.

The problem, from the industry’s point of view, is the lengthy time it takes for test results.

The tests currently done for antibiotics in milk take just minutes to complete. But the new tests could take a week or more to determine if the drugs were present in the milk.

Milk moves quickly onto store shelves or to factories where it is made into cheese or other products. The industry worried that, under the F.D.A. plan, by the time a load of milk was found to be contaminated, it could already be in consumers’ refrigerators, and that could lead to recalls.

One Northeast cooperative, Agri-Mark, sent a letter to its members last month instructing them to dump milk if it had been tested by the F.D.A. “Agri-Mark must ensure that all of our milk sales, cheese, butter and other products are in no danger of recall,” the letter said.

Other industry executives said that processing plants would refuse to take any milk from a farm that had been tested until the results showed it was drug-free, meaning farmers could end up dumping milk for a week or more while waiting.

The F.D.A. plan was also criticized by state officials that regulate the dairy industry.

In a sharply worded Dec. 29 letter, the top agriculture officials of 10 Northeastern states, including New York and Pennsylvania, which are both leading dairy producers, told the F.D.A. that its plan was badly flawed. Among other problems, the letter said, forcing farmers to dump large quantities of milk could create environmental problems.

The F.D.A. said it would consider the regulators’ comments as it reviewed its testing plan.

Recipes for Health: Soba Noodles in Broth With Sweet Potato, Cabbage and Spinach

Posted: 26 Jan 2011 12:00 AM PST

This simple Japanese soup can be served as a meal or as a starter. As the sweet potatoes and cabbage simmer in the broth of your choice, they infuse it with sweetness. Spinach is added at the last minute, and the soup is served with cooked soba noodles.

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Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

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6 cups kombu dashi, chicken stock or vegetable stock

Salt to taste

6 ounces Japanese soba noodles, cooked and tossed with 1 tablespoon sesame oil

1 large or 2 small sweet potatoes (about 3/4 pound), peeled and sliced about 1/4 inch thick (cut in half lengthwise first if fat)

2 cups shredded cabbage

1 6-ounce bag baby spinach, rinsed

2 tablespoons minced chives

Note: Sweet potatoes may be labeled as yams. Look for dark orange flesh.

1. Bring the stock to a simmer. Taste and adjust seasoning, adding salt if desired. Add the sweet potatoes and cabbage, and simmer 15 minutes until the vegetables are tender.

2. If the noodles have been refrigerated, warm them by placing them in a strainer and dipping the strainer into the simmering broth. Then distribute the noodles among four to six soup bowls. Add the spinach to the stock. Cover, and turn off the heat. Leave for three minutes. Ladle the soup into the bowls, taking care to distribute the vegetables evenly. Sprinkle the chives over each serving, and serve.

Yield: Serves four as a main dish, six as a starter.

Advance preparation: The noodles can be cooked ahead of serving and kept in the refrigerator for a couple of days. The stock can also be made a day or two ahead.

Nutritional information per serving (four servings): 265 calories; 4 grams fat; 1 gram saturated fat; 0 milligrams cholesterol; 51 grams carbohydrates; 6 grams dietary fiber; 155 milligrams sodium (does not include salt to taste); 10 grams protein

Nutritional information per serving (six servings): 177 calories; 3 grams fat; 0 grams saturated fat; 0 milligrams cholesterol; 34 grams carbohydrates; 4 grams dietary fiber; 103 milligrams sodium (does not include salt to taste); 6 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Skin Deep: Full-Service Gyms Feel a Bit Flabby

Posted: 26 Jan 2011 12:50 PM PST

IS the gym passé?

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Oscar Hidalgo for The New York Times

At OrangeTheory in Fort Lauderdale, Fla., above and left, small-group training is offered and people can pay by the class.

It used to feel worthwhile to commit to an annual membership at an everything-and-the-kitchen sink gym featuring high-spirited classes, top-of-the-line cardio machines, weights — and perhaps a shot at striking up a conversation with Ms. Lithe sipping a post-workout smoothie.

But these days, the idea of a full-service gym is as stale as yesterday’s sweat-soaked towel. Up to 45 percent of fitness-club members quit going in any given year, according to the International Health, Racquet & Sportsclub Association.

For all their ads promising to stir motivation, gyms have failed to do so. “Up until the last six years, it’s been relatively easy to sell memberships, and to replace people going out the back door with people coming through the front door,” said Michael Scott Scudder, a consultant who advises health clubs and conducts up to 15 industry surveys annually. “Not so anymore. We’ve come to a point that we can’t sell enough membership in the industry to cover the attrition rate.”

Blame the gym’s now-ubiquitous flat-screen TVs and the fact that iPods are de rigueur, said Jonathan Fields, a marketing consultant in Manhattan who has helped found personal-training gyms and yoga studios. “Now everybody’s plugged in,” Mr. Fields said. “In the 70s, they came for community. Now they come in and disassociate themselves from everyone in the club. It’s killing the health club.”

Kitchen-sink gyms also face pressure from operations like Planet Fitness, a chain founded in 1992 that offers Cybex treadmills and weight machines, but which does not have Zumba classes or perks like towels — and charges $10 a month.

Today’s consumers wonder why they should pay more for a so-called big-box gym when they can get the laissez-faire approach for less. Michael Grondahl, the chief executive of Planet Fitness, who recently eliminated personal training at his 406 franchises, does not believe that he is in the motivation business. A staff trainer still offers 30-minute sessions for groups of five, but Mr. Grondahl said he does nothing to keep members coming. “I can’t keep you motivated to do something you don’t want to,” he said.

Rich Boggs, a creator of the original step and the chief executive of Body Training Systems, which licenses group fitness classes to 700 clubs nationwide, said this hands-off model won’t work for people who aren’t self-starters (which is to say: most of us). “You can’t get the cheapest and the best at the same time, unless you know precisely what you want to do, you’re Equipment Guy and you don’t need any help,” he said.

But that is a fair description of Chanie Raykoff, a special educator who works out at Blink Fitness, a low-price spinoff of the cushy Equinox. “I like to get in and out,” said Ms. Raykoff, at the NoHo branch on a recent Tuesday evening. “I do weights and cardio. I am not social.” Indeed, conversation was sparse during an hourlong visit to the gym’s sleek workout floor.

Socializing, however, is key to long-term exercise success, said Terry Blachek, the president of International Consulting, which helps clubs improve member retention. “We know you’ve got to engage the client,” Mr. Blachek said. “It’s got to be a challenge for them. And we know you’ve got to connect the client in a meaningful way to others.”

Mr. Blachek has some experience in this: He was the executive vice president at the once-chic fitness chain Crunch in the 1990s, when its novelty group workouts, like the Firefighter and Cycle Karaoke, were the rage. “Those classes were the claim to fame for Crunch,” he said. “They connected clients to their peers.”

These days, “loyalty has dropped dramatically,” said Casey Conrad, a consultant with 25 years in the fitness industry. One reason: A decade ago, full-service gyms didn’t offer today’s “unbundled” memberships that let consumers choose what perks to pay for. Some fitness seekers have been trying an à la carte approach, taking specialized pay-as-you-go classes like those offered by the stationary-cycling competitors Flywheel Sports and SoulCycle, or Core Fusion at the Exhale Spa, rather than committing to a gym membership.

“You can do whatever suits your fancy when it does,” said Jessica Underhill, a personal trainer who writes the blog Fit Chick in the City, referring to the pay-per-class approach. She tried so many studio classes in 2010 that she thought she had “exercise A.D.D.,” but came to favor the Bar Method, a body-sculpting class held at studios from Manhattan to Marina del Rey, Calif., because, she said, instructors rattle off names as they offer corrections and make her feel as if she is a part of something.

“They acknowledge that you are a consumer, and are friendly at the same time,” Ms. Underhill said. “It doesn’t feel stale or super crisp and clean. It’s about connection.”

And no one is going to turn into a lifer akin to Jack LaLanne, the fitness pioneer who died this week, without a reason to work past the aches and drudgery of exercise. “There’s no question that the social element is a huge, huge piece to getting participation,” Ms. Conrad said. “I travel a lot, and when I miss yoga class, they are like, ‘Casey, where have you been?’ ”

The New Old Age: Retirements Swallowed by Debt

Posted: 26 Jan 2011 10:34 AM PST

For a Medicaid Cost-Cutter From Wisconsin, a More Complicated Job in New York

Posted: 25 Jan 2011 11:01 PM PST

ALBANY — Two years ago, Gov. James E. Doyle of Wisconsin knew that he needed to cut hundreds of millions in Medicaid spending in his state.

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He could have done it the conventional way, imposing lower payment rates across the board for providers, while preparing himself for battle with the health care industry. Instead, he negotiated with lawmakers on the total dollar figure to be saved: ultimately, $625 million over two years. Then he instructed his Medicaid director, Jason A. Helgerson, to gather Wisconsin’s hospital executives, labor leaders and others with an interest in the outcome and figure out where the savings would come from.

“I wouldn’t say they all were happy with us,” Mr. Doyle said about the process, “but I think they felt they all got a fair shake.”

Wisconsin is not New York, where Mr. Helgerson, 39, now has the task of reining in the state’s troubled Medicaid program. Gov. Andrew M. Cuomo recruited him to find billions of dollars in savings to help close the state’s more than $9 billion budget gap in the next fiscal year.

In Wisconsin, state and federal spending on Medicaid this fiscal year is projected to total $6.2 billion. In New York, it will be more than $53 billion. In Wisconsin, about a million people are enrolled in Medicaid, which pays for health care for the poor. In New York, enrollment is approaching five million.

And perhaps most significant, in Wisconsin, Mr. Helgerson was charged with slowing growth, not making huge cuts, as Mr. Cuomo wants. In the two-year period when he worked on the savings, Wisconsin expanded eligibility for its Medicaid program, and overall spending grew nearly 20 percent.

“This is a tough, difficult budget,” Mr. Helgerson said in a recent interview. “The hope is through this engagement process, we’ll be able to generate some new, additional ideas that might be able to replace some challenges that otherwise would have to go into the budget.”

In interviews, health care officials in Wisconsin generally praised Mr. Helgerson’s handling of the cuts, though his work was not without critics. Some said that the process was not as collaborative as described and that some of the measures he approved would produce only one-time saving or involved creative accounting, like deferring $127 million in managed care payments to the next fiscal year. Other measures took the form of more traditional rate cuts, particularly to managed care providers and pharmacies.

Nevertheless, hospital and union officials in New York said they were encouraged by Mr. Helgerson’s record of producing cost savings without making enemies or reducing patient care.

It is not likely to go as smoothly in New York, where officials would not commit to accepting whatever cuts emerged from the work of the so-called Medicaid Redesign Team that Mr. Cuomo appointed shortly after taking office this month. Their cautiousness underscores the delicate negotiating position that Mr. Helgerson — and, by extension, Mr. Cuomo — finds himself in.

Mr. Cuomo does not want cost savings to come simply from one big cut in the rates paid to providers.

“Let’s see if we can’t actually find efficiencies in the program so we actually provide a better service for less money,” Mr. Cuomo said in his State of the State address.

Enter Mr. Helgerson, who before becoming Mr. Doyle’s Medicaid director worked as a policy adviser or budget official for the mayor of San Jose, the Milwaukee public school system and the Milwaukee mayor. (He takes no shame in his fascination with balancing budgets: when he signed up for Twitter, he chose the user name @policywonk1.)

To find the savings that Mr. Doyle and lawmakers had agreed on, Mr. Helgerson assembled nine committees for different constituencies, including physicians, hospital executives and pharmacists.

For three hours at a time, Mr. Helgerson and other state officials huddled with each group, writing idea after idea on big easels. They also solicited ideas from the public via a Web site, a practice that Mr. Cuomo has replicated.

More than 500 ideas were proposed, and after three months of analyzing the numbers in various ways, Mr. Helgerson and his boss, the secretary of Wisconsin’s Department of Health Services, reached the magic $625 million figure.

The savings came from 71 measures, like teaming up with Michigan on a contract to buy adult diapers in bulk (savings: $2.2 million) or checking the market price for generic medication more frequently and updating payment rates accordingly ($41 million).

Stricter Oversight Urged for Defibrillators

Posted: 25 Jan 2011 10:30 PM PST

A federal advisory panel on Tuesday called for stricter oversight of the defibrillators available in many schools, gyms, lobbies and other places that are used by the public to try to save victims of major heart attacks.

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Amy Sancetta/Associated Press

External defibrillators are credited with saving 500 lives a year in the United States and Canada.

Food and Drug Administration staff also recommended tighter controls over the automated external defibrillators, citing concerns about product recalls and reliability. Over the last five years, according to a new agency report, there have been 68 recalls and more than 22,000 reports of malfunctioning devices. The F.D.A. staff said manufacturers followed up on only one-third of the reported problems.

More than a million automated defibrillator devices are available in the United States and Canada. They have been credited with saving nearly 500 lives a year.

The devices have been classified as high risk but under a grandfathering clause have been regulated as if they were lower risk, which allowed them to be brought onto the market faster. Devices in the high-risk category must meet requirements for approval before they can be sold, and may require more study, reporting or other controls to assure safety and effectiveness.

Manufacturers of the devices in the United States had sought a lower level of government oversight that would essentially continue the review system now in place. They argued that red tape would strangle innovation and raise prices. The manufacturers also said the vast majority of malfunctions arose from a self-reporting mechanism on the device and rarely affected people needing help.

But at the end of a daylong hearing on Tuesday, Dr. John W. Hirshfeld Jr., chairman of the advisory panel and a professor of cardiovascular medicine at the University of Pennsylvania, said, “There are a number of signals that raise questions about quality and reliability.”

The F.D.A. usually follows advisory committee recommendations.

Dr. Bram D. Zuckerman, director of the division of cardiovascular devices in the F.D.A. Office of Device Evaluation, said the companies would have 12 to 18 months after publication of a new rule to develop any additional studies or reports required to prove safety and effectiveness.

“There’s no question these are life-sustaining, life-saving devices,” he said.

The automated defibrillators, which cost about $2,500 apiece, can quickly and simply detect whether a collapsed person has the type of life-threatening abnormal heart rhythm that can be jolted back into normal rhythm, and if so, deliver the jolt. They have revived people without pulses.

An estimated 300,000 Americans suffer sudden cardiac arrest each year.

All of the doctors and professors on the F.D.A.’s Circulatory System Devices Panel acknowledged the value of the public defibrillator, but most agreed the devices should be put into a high-risk category to assure stronger product reviews.

The devices are manufactured by Cardiac Science Corporation, CU Medical Systems, Dfibtech, Heartsine Technologies, Philips Medical Systems, Physio-Control and Zoll Medical. They are already subject to manufacturing standards, engineering testing, animal testing when a new electrical waveform is proposed and certain clinical testing.

But the F.D.A. staff and advisers were critical of the lack of follow-up to malfunction reports, with some saying they were concerned the lifesaving devices might be accessible but inoperable.

There was no official vote, but only two or three of about a dozen panel members spoke in favor of the medium-risk category.

One of them was Dr. Myron L. Weisfeldt, a defibrillator pioneer and chairman of the department of medicine at Johns Hopkins University. He said the recalls were “concerning,” but mostly based on industry self-regulation, not patient problems. People who receive the treatment for ventricular fibrillation have a 42 percent survival rate, he said.

“The technology’s been around 26 years and its effectiveness when you have a safe and reliable device is beyond question,” Dr. Weisfeldt said.

With Poem, Broaching the Topic of Death

Posted: 24 Jan 2011 11:20 PM PST

FORT DEFIANCE, Ariz. — Mitzie Begay, an elegant 76-year-old Navajo, can interpret the nuances of her language and traditions with contemporary verve and understated wit — qualities that make her a good fit for a job that could hardly have been imagined in the Navajo Nation a generation ago.

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Dale Kruzic

RESERVATION Health workers visit elderly Navajos at home in isolated communities.

Ms. Begay, whose title is cross-cultural coordinator for the home-based care program at the Fort Defiance Indian Hospital here in northeastern Arizona, helps Navajos deal with the complex and confusing process of decision-making at the end of life.

In Navajo culture, talking about death is thought to bring it about, so it is not discussed. A dead person’s name is never spoken. Only designated tribal members are permitted to touch and bury the dead.

So it is up to Ms. Begay and her colleagues to find ways to teach people (many with little or no English) about things like living wills, durable powers of attorney, do-not-resuscitate orders, electroencephalograms, feeding tubes and ventilators. In spite of the taboos, they are trying to find a comfortable way to begin a conversation with patients and their families about death and dying.

Until last month, the program’s director was Dr. Timothy Domer, a geriatrician who practiced medicine for more than 20 years in this remote, high-desert, red-rock landscape on the eastern fringe of the vast Navajo reservation. Its goal, he said, is to keep elderly patients healthy, starting with a thorough physical exam and a comprehensive, interdisciplinary assessment, followed by home visits.

Dr. Domer, who is moving to New York State to practice geriatrics and palliative care, said it soon became clear that when it came to end-of-life matters, his patients had a different perspective from many other Americans.

“When I explained to an old Navajo patient of mine that we sometimes have to shock the heart to get it started, he said, ‘Why would anybody do a crazy thing like that?’ ” he said. “That made me think there were people who didn’t necessarily want the standard resuscitative efforts that we routinely practice at the end of life.”

When Dr. Domer started the home-based care program five years ago, he reviewed hospital records to see how many charts contained advance directives. “There were none — zero,” he said.

For patients who had terminal illnesses, Dr. Domer wanted to be able to provide hospice and palliative care.

“Our goal is not just to change the way people die,” he said, “but to change the way dying people live, and how their families experience and will remember the death.”

On this day Ms. Begay and Gina Nez, the program’s director of nursing, are bumping along in a four-wheel-drive S.U.V. to visit elderly patients in isolated communities. They drive past hogans, the six-sided traditional Navajo dwellings, past herds of cattle and sheep that dot the grass meadows.

“At first I was uncomfortable,” Ms. Begay said about her introduction to end-of-life discussions. “But the staff got together and we talked about it, and we agreed on a way to approach it.”

The vehicle was a poem: “When that time comes, when my last breath leaves me, I choose to die in peace to meet Shi’ dy’ in” — the creator. Written in both Navajo and English, it serves to open a discussion about living wills and advance directives.

Fewer than 30 percent of Americans have signed advance directives for health care. But Dr. Domer says almost 90 percent of patients in the program have signed the poem and other standard directives.

“Our elders tell us they want to die with dignity — the way they lived,” he said. “We’ve changed how patients live their final days by opening the discussion on death and dying, and giving patients and families the opportunity to tell us what is important to them.

“Before we started this program, the subject was generally avoided out of ‘cultural sensitivity,’ depriving patients and families of preparing for death spiritually, emotionally and practically.”

When someone dies in the family hogan, for example, a hole is made in the north wall to let the good spirit out, and then the hogan is abandoned.

As Doctors Age, Worries About Their Ability Grow

Posted: 25 Jan 2011 03:13 PM PST

About eight years ago, at the age of 78, a vascular surgeon in California operated on a woman who then developed a pulmonary embolism. The surgeon did not respond to urgent calls from the nurses, and the woman died.

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Even after the hospital reported the doctor to the Medical Board of California, he continued to perform operations for four years until the board finally referred him for a competency assessment at the University of California, San Diego.

“We did a neuropsychological exam, and it was very abnormal,” said Dr. William Norcross, director of the physician assessment program there, who did not identify the surgeon. “This surgeon had visual-spatial abnormalities, could not do fine motor movements, could not retain information, and his verbal I.Q. was much lower than you’d expect.”

Yet “no one knew he had a cognitive deficit, and he did not think he had a problem,” Dr. Norcross continued. The surgeon was asked to surrender his medical license.

One-third of the nation’s physicians are over 65, and that proportion is expected to rise. As doctors in the baby boom generation reach 65, many are under increasing financial pressures that make them reluctant to retire.

Many doctors, of course, retain their skills and sharpness of mind into their 70s and beyond. But physicians are hardly immune to dementia, Parkinson’s disease, stroke and other ills of aging. And some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing. “My guess is that John Q. Public thinks there is some fail-safe mechanism to protect him from incompetent physicians,” Dr. Norcross said. “There is not.”

Often the mechanism does not kick in until a state medical board has found it necessary to discipline a physician. A 2005 study found that the rate of disciplinary action was 6.6 percent for doctors out of medical school 40 years, compared with 1.3 percent for those out only 10 years.

In 2006, a study found that in complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older, though there was no difference between younger and older doctors in routine operations.

Patient advocates note that commercial pilots, who are also responsible for the safety of others, must retire at age 65 and must undergo physical and mental exams every six months starting at 40. Yet “the profession of medicine has never really had an organized way to measure physician competency,” said Diane Pinakiewicz, president of the nonprofit National Patient Safety Foundation. “We need to be systematically and comprehensively evaluating physicians on some sort of periodic basis.”

Some experts are calling for regular cognitive and physical screening once doctors reach 65 or 70, and a small cadre of hospitals have instituted screening for older physicians. Some specialty boards already require physicians to renew their certification every 7 to 10 years and have toughened recertification requirements. But such policies have met resistance from rank-and-file doctors.

“I do not believe that diminished competence attributable solely to age is a significant factor in the underperformance of most poor-performing physicians,” Dr. Henry Homburger, 64, professor of laboratory medicine at the Mayo Clinic, said by e-mail. Mental illness like depression, substance abuse and a “failure to maintain competence through continuing education far outweigh age as causes of poor performance, in my opinion,” he wrote.

Others doubt that a single type of exam can be used to assess the performance of doctors from a variety of specialties. “More research is needed for us to define what combination of cognitive and motor issues are important,” said Dr. Stuart Green, a member of the ethics committee of the American Academy of Orthopaedic Surgeons.

Physicians do have to meet minimal requirements to continue to practice. To renew a medical license in most states, doctors must complete a certain number of hours of continuing medical education every year or two.

This does not impress experts like Dr. Norcross. “You can be asleep during those courses and no one would know,” he said.

Even the tougher new policies of specialty boards do not usually apply to older physicians, who, because of “grandfather” clauses, are not required to renew their certification — an expensive, time-consuming process.

They are being encouraged to do so voluntarily, but few do — less than 1 percent of the 69,000 so-called grandfathered members of the American Board of Internal Medicine, for example.

Doctors with mild cognitive impairment may not be aware they have a problem or their performance is flagging. Changes are often subtle at first: a person may not be able to recall words, learn new material, apply knowledge to solving problems or multitask.

These deficits can make it hard to carry out the latest recommendations for diagnosis and treatment, learn new computer-based technology, remember prescribing details about medications, or function well in a stressful environment like the emergency room.

Only when a doctor’s behavior starts to become odd are other physicians, nurses and patients likely to take notice.

Cases: A Young Life Passes, and a Ritual of Birth Begins

Posted: 24 Jan 2011 10:40 PM PST

My hands trembled as I grasped the tiny sleeve of skin with my forceps and separated it from his pale, still penis. He lay weirdly motionless on a utility table, which I had draped with a slate-blue operating-room towel.

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Vivienne Flesher

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A few feet away, his young parents sat quietly wrapped in each other’s arms. Several family members and friends stood silently around the periphery of the small hospital room, whose gray-green walls enveloped us dispassionately.

The pregnancy had been uneventful. A month before the due date I had received a familiar, reluctant, yet eager call about arranging a bris, the ritual Jewish circumcision performed on the eighth day of life. The expectant parents promised to call back after delivery to confirm the date and time so they could order the deli platters.

Like many parents nowadays, this couple preferred a medical circumcision — respectful of religious tradition but performed by a physician, with local anesthesia and sterile technique easing the anxiety associated with an old-fashioned bris on a kitchen counter. This is where I came in.

As a urologic oncologist, I ordinarily focus on those afflicted with cancer, often at life’s end. So 17 years ago, I became a certified mohel, hoping to marry my surgical skills and my knack for calming nerves with the hopeful optimism of growing families. A bris provides an intimate and reinvigorating view of life’s beginning.

The ninth month passed, but the happy call never came. A week after the mother’s due date, I learned, the fetus’s heart rate had slowed alarmingly and he was delivered by emergency Caesarean section. Born limp and gasping, he was resuscitated and whisked to the neonatal intensive care unit.

But three days of 21st-century medical heroism failed to provide even a glimmer of hope. A flat electroencephalogram confirmed the dire prognosis. His brief life was waning.

The mother’s best friend called me with the news.

“They’d still like you to perform a bris but don’t want to put him through any unnecessary pain,” she said. “Can you do it after he dies?”

I could, it seemed. My rabbi assured me that Jewish tradition allows for such circumstances. The ceremony is different, of course — there’s no talk of bar mitzvah or marriage, and the prayer for healing is redirected at the grieving family. A post-mortem circumcision allows a moment of normality before the immense loss must be confronted. The rabbi taught me what to say to make the ceremony kosher: the Hebrew phrase “Ani hu ha’Elohim” (loosely translated as “Above all else, there is God”), repeated seven times.

The hospital staff removed the baby from the ventilator, took out the intravenous lines, swaddled him and handed him to his parents. They were led to the hospital room, where they sat gently cradling their warm newborn son for just an hour as pink faded to gray.

Then, like a candle suddenly extinguished by a gust of wind, life left. A sad emptiness remained, as if the air were pierced by a pungent, thin plume of black smoke, rising and quickly dissipating. He was gone. No future, only a past.

Explaining to those now gathered the meaning of what we were to witness, I began the procedure I had done a thousand times. I took the baby from his father, unwrapped his soft blanket and gently laid him on the utility table. But today there were no squirming legs, no lidocaine injection, no smiling grandparents recalling their own son’s bris a generation ago. Just a drop of purple blood.

I must have fumbled with the instruments a little too long. “It doesn’t have to be perfect, Doc,” the young father called out, breaking the tension that had gripped the room. Cool relief wafted through in quiet chuckles.

Actually it does, I thought — this one has to be extra perfect. This was their only unsullied moment with him, all they might remember. With no life ahead to pin dreams on, he had paused for one intense and ephemeral instant before being wrapped in the ancient tradition of his ancestors.

“Ani hu ha’Elohim...Ani hu ha’Elohim... .” I barely recognized my own voice echoing the incantation, the words punctuated by muffled sobs in the room. As I faltered, I drew strength directly from the young parents. Lost as they must have felt, their faces remained strangely calm. I could feel their approval, their encouragement, their stamina. In turn, I reflected it to support them. I was the instrument, and they allowed no fumble. Amen.

Two years later they called again: “We’re having a boy, and we’d like you to do the bris.” The pregnancy had been uneventful. I melted into my chair, almost overcome with dual emotions. My heart throbbed with the memory of their pain, yet that pain was tempered with their resolution and new enthusiasm. It felt like water of such extreme temperature that it could be either hot or cold.

A month after that, we had a happily pedestrian conversation about date and time. Eight days later, the spring sun radiated through a brilliant blue sky into their home. The smells of brewed coffee, warm bagels and fresh lox overlay the chatter of arriving guests. Suffused with morning light, the living room slowly filled with each of the previous attendees. Wearing giddy smiles and energized with new hopes and dreams, the young parents again handed me their newborn son.

Dr. Mark S. Litwin is a professor of urology and public health at the University of California, Los Angeles.

Global Update: Pakistan: Short Training for Women Workers Goes Far in Saving Newborns’ Lives

Posted: 25 Jan 2011 11:58 AM PST

A new study suggests that “lady health workers,” as Pakistan calls them — women trained as part of a government program to give care to poor people in rural areas — can make a difference in saving the lives of newborns.

Researchers from Aga Khan University in Karachi followed almost 50,000 households in two health districts for two years. The areas where the women were assigned to work had 21 percent fewer stillbirths and 15 percent fewer newborn deaths than in other areas. That success was achieved even though the health workers generally had only 10th-grade educations and one extra week of training for the project. Also, they failed to hold almost half the planned group sessions for pregnant women and visited only a quarter of the babies within a day of birth.

The workers advised pregnant women to go to clinics for checkups and vitamins, and to give birth at clinics. They handed out “birth kits” with soap and clean razors to reduce the chance that cutting the umbilical cord would transmit tetanus. They instructed the widely used professional midwives, known as dais, in skills like getting newborns to breathe and giving mouth-to-mouth resuscitation. And they asked the dais to encourage mothers to keep premature babies warm instead of washing them in cold water, and to breast-feed them immediately.

The study, which was paid for by the World Health Organization, Save the Children USA and the Bill and Melinda Gates Foundation, was published online by The Lancet on Jan. 14.

Books: A Pound of Prevention Is Worth a Closer Look

Posted: 25 Jan 2011 12:02 PM PST

Make no mistake about it: modern medicine is a religion. For all the complicated science, the bottom line is that either you believe in the science or you don’t. If you are an average citizen and have your doubts, then you can just go about your business. But suppose you are a doctor and have your doubts. Then what?

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Then, if you are smart and courageous enough, you may go the route taken by Dr. H. Gilbert Welch and his colleagues at the Dartmouth School of Medicine over the last decade or so, as they persistently, politely tack their theses to the church door. Their writings (some for this newspaper) add up to a substantial protest against portions of the received wisdom that keeps the modern medico-industrial complex humming along.

Are they lunatics, heretics or prophets? I’d say the last, but never mind what I think; all health care consumers can and should decide this one for themselves, and the group’s new book is a fine place to begin, as they cast a critical eye on our national obsession with preventive medicine.

This is the field of endeavor that aims to keep healthy people healthy, either by warding off fatal illness like heart disease or cancer before it begins, or by detecting it at such an early stage it has yet to cause symptoms. The apple is the prototype here (take one daily). Unlike that useful fruit, however, preventive medicine keeps healthy people and their doctors joined at the hip, what with the routine checkups, the monitoring of breasts, colons, prostates, hearts, lungs and thyroids, the tuning of blood pressure, the jiggering of cholesterol, and the obsessive tracking of a few dozen biochemical parameters in routine blood tests.

It all makes intrinsic sense. Who wouldn’t want a tiny little cancer instead of a big bad cancer, or a touch of high blood pressure instead of the full-blown thing? In a perfectly configured world, finding and fixing every problem early on would guarantee long-term blooming health. But, alas, the world of medicine is far from perfect.

Take, for example, high blood pressure, called the “silent killer” because until it gets high enough to damage organs, it causes no discomfort at all. As the authors remind us, President Franklin D. Roosevelt’s death at age 63 was clearly a result of uncontrolled high blood pressure in the days before it was a recognized medical problem. Had he been treated with today’s drugs, he almost certainly would not have died so young.

But for a person with very mildly elevated blood pressure — or perhaps with the newly created condition of “prehypertension,” with readings at the upper limit of normal — the calculus is quite different. In mild disease, the risks of harm from medication begin to loom very large as the risk of harms from the disease falls very low. For some people, especially the fragile elderly, the problems of the treatment can predominate.

The authors deplore our habit of showering prescription drugs on those unlikely to benefit from them. They trace it directly to the fact that once the experts have drawn the line in the sand that separates “health” from “disease,” we all tend to forget that both entities are etched in shades of gray, not the black and white the terms imply.

Similarly, the line between “normal” and “abnormal” is not the closed border most people envision but a no man’s land of substantial width. And so in our wild enthusiasm for seeking out tiny abnormalities, we often find them — thanks especially to the wondrous eyes of the latest high-priced scanners. Not necessarily the abnormalities we were looking for, but abnormalities nonetheless.

Talk about too much information. Many of these little bobbles aren’t problems until we find them. Counterintuitively, that includes some small cancers likely to stay quiescent for years, or even to vanish on their own. But once they are identified, they have to be dealt with. So: more scans, more drugs, more side effects, more anxiety and depression and all the usual fallout of illness ... but all in fundamentally healthy people.

As the world is currently configured, the authors point out, doctors are never punished for overdiagnosis, no matter how much havoc may be wrought by untrammeled overtesting. It is perceived underdiagnosis that arouses legal and moral wrath.

Is that the way it should be? One of the big strengths of this relatively small book is that if you are inclined to ponder medicine’s larger questions, you get to tour them all. What is health, really? Why do we sometimes equate “normal” with “desirable” when it often means just the opposite? In the finite endeavor that is life, when is it permissible to stop preventing things?

And if the big questions just make you itchy, you can concentrate on the numbers instead: The authors explain most of the important statistical concepts behind evidence-based medicine in about as friendly a way as you are likely to find.

But if numbers make you as unhappy as big questions do, if you just want someone all dressed up in white to tell you what to do so you can do it and get it over with, that’s fine. Actually, it’s perfectly normal. You are accustomed to the rhythms of the old-time religion. But don’t forget, you can always change your mind.

Vital Statistics: Birth Control Update, in Thousands of Interviews

Posted: 24 Jan 2011 10:48 PM PST

To find out what American women are doing about birth control these days, the National Center for Health Statistics conducted some painstaking research: 80-minute interviews with each of 7,356 women ages 15 to 44.

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Contraceptive Use

The interviews were done in the women’s homes by trained female interviewers from July 2006 through December 2008. They gathered data on births, pregnancies, marriages and cohabitations, sterilization operations, and other social and demographic characteristics.

Similar surveys were done with comparable samples of women in 1982, 1995 and 2002, and some findings “are quite persistent” over the decades, said an author of the report, William D. Mosher, a statistician with the center.

“The pill and sterilization have been the leading methods for 25 or 30 years,” he said.

In the latest survey, 61.8 percent of the women interviewed were using contraception, up from 55.7 percent in 1982. More than 17 percent were using the birth control pill, compared with 15.6 percent in 1982, and female sterilization increased to 16.7 percent in 2006-8 from 12.9 percent in 1982. Ten percent of women relied on their partner’s use of a condom, up from 6.7 percent in 1982.

By contrast, the rate of male sterilization, 6.1 percent, has not changed.

The percentage of women who had used emergency contraception at least once increased to 10 percent, from 4 percent in 2002.

Seven out of 10 women said they had used some form of contraception at their first incidence of intercourse, and use was directly correlated with the education level of the woman’s mother.

For those whose mothers had no high school diploma, the rate was 52.8 percent; for daughters of high-school graduates it was 69.3 percent; for daughters of women with some college, 75.5 percent; and for daughters of college graduates, 83.9 percent.

Contraceptive use also varied by race. In the 2006-8 survey, 64.7 percent of white women and 63.9 percent of Asians used birth control, compared with 58.5 percent of Hispanics and 54.5 percent of blacks. NICHOLAS BAKALAR

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Q & A: Caffeine Concerns

Posted: 24 Jan 2011 10:03 PM PST

Q. Can too much caffeine kill you?

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A. In very rare cases, overdoses of caffeine have been fatal. The estimated fatal oral dose, which varies because of factors like weight, is 5 grams to 10 grams.

It would be very hard, probably impossible, to ingest enough caffeine to kill yourself by drinking ordinary coffee. According to government estimates, an eight-ounce cup of brewed coffee contains 60 to 120 milligrams of caffeine. Assuming a caffeine content on the high side and a fatal dose on the low side, you would have to drink at least 42 cups at a sitting.

But caffeine is found in higher amounts in energy drinks, medications and herbal preparations.

Concentrations of caffeine in blood plasma that are higher than 15 milligrams per liter of blood can cause toxic reactions, and caffeine overdoses are a relatively common cause of poisoning emergencies, with 4,183 such cases reported by the American Association of Poison Control Centers in 2007.Only one death occurred among those cases.

When caffeine does kill, the reported causes are abnormal heart rhythms, seizures and breathing in vomit.

C. CLAIBORNE RAY

Readers are invited to submit questions by mail to Question, Science Times, The New York Times, 620 8th Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com. Questions of general interest will be answered in this column, but requests for medical advice cannot be honored and unpublished letters cannot be answered individually.

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City University’s 23 Campuses Are the Latest to Ban Smoking

Posted: 25 Jan 2011 10:20 PM PST

Last summer, the University at Buffalo banned smoking on its three campuses. Last month, Columbia University approved a measure that prohibits smoking within 20 feet of buildings.

And on Monday, the trustees of the City University of New York, the largest urban higher-education system in the country, voted to forbid smoking on all 23 of its campuses, from the College of Staten Island to Lehman College in the Bronx.

CUNY’s move is the latest in a wave of comprehensive smoking bans on college campuses nationwide, a trend that began about five years ago and has gathered momentum in recent months. The American Nonsmokers’ Rights Foundation, a nonprofit advocacy group, reported this month that at least 466 campuses had completely banned smoking or passed resolutions to do so.

Unhealthy habits, from keg parties to all-nighters, have long been associated with the college experience. All the more reason for the prohibitions, say proponents of the bans and public health experts, who feel that the campus antismoking rules send an important early message to young people about healthy lifestyles.

“It makes a lot of sense,” said Cynthia Hallett, executive director of the nonsmokers’ foundation, which is based in Berkeley, Calif. “My daughter is going off to college this year, and the campus is a student’s new home and work and play environment.”

CUNY officials, who estimate that 13 percent of their students, faculty members and staff members smoke tobacco, noted that the ban was prompted in part by the recent creation of the university’s School of Public Health. Campuses will have until September 2012 to impose the rules, allowing them time to mount educational campaigns, post no-smoking signs and provide counselors trained in helping smokers quit.

But campuses are free to forbid smoking before that deadline, said Alexandra W. Logue, CUNY’s executive vice chancellor and university provost. Dr. Logue, who has a background in experimental psychology, said the new restrictions could impel smokers to give up the habit. “The more you can remove cues in the environment that are associated with that addiction, the less craving the smoker will feel,” she said.

John Jay College of Criminal Justice, a CUNY school that will expand its complex on the West Side of Manhattan in the fall, will prohibit smoking on a planned rooftop commons. The landscaped space, with grassy areas and benches, will stretch over most of a block.

Karen Kaplowitz, a professor of literature at John Jay, is a former smoker who served on the advisory task force that recommended the CUNY smoking restriction. “Before this ban, we would have had to permit smoking,” she said. “But now we’re going to have a beautiful, tobacco-free campus in the middle of Manhattan that is unthreatened by cigarette smoke and butts.”

Some of CUNY’s most urban colleges, like Hunter and Baruch in Manhattan, may not notice much of a difference, since the university cannot prohibit smoking on public sidewalks. The ban will be felt more on campuses with ample green space between buildings, like City College, Queens College, College of Staten Island and Lehman College.

Reaction to the restrictions did not fall along predictable lines on Monday. At City College, where students hurried between buildings in the bitter cold, Dan Cardillo, a sophomore from Greenwich, Conn., criticized the new rule, even though he does not smoke himself.

“I think it’s a stupid thing to do,” he said. “It’s a college campus. We should be treated like adults. If it’s not illegal, they should not ban it here.”

His classmate Jennifer Santiago, a senior from the Bronx who smokes half a pack of cigarettes a day, supported the ban. “I kind of agree with it even though I’m a smoker — for the sake of other people not breathing secondhand smoke,” she said. “People got used to the idea by not smoking in bars.”

If city officials have their way, large swaths of the five boroughs will soon join the CUNY campuses. City Councilwoman Gale A. Brewer sponsored a bill in September that would ban smoking in 1,700 parks and along 14 miles of beaches. On Monday, she said that the mayoral and Council staffs were still working on the final details, but that the measure could go before the Council for a vote next month.

At the University at Buffalo, the largest institution in the State University of New York system, the decision to ban smoking on the three campuses, covering more than 1,350 acres, followed a restriction on smoking within 100 feet of buildings. Joseph A. Brennan, a spokesman for the university, said that professors at the School of Public Health and Health Professions and alumni in the medical profession were “a driving force” behind the complete ban.

“As an educator of future physicians, we teach our students to encourage their patients not to use tobacco,” he said. “So we should walk our talk and ban ourselves.”

Nate Schweber contributed reporting.

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Well: Central Heating May Be Making Us Fat

Posted: 26 Jan 2011 09:23 AM PST

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Well: Are You Getting Enough Calcium and Vitamin D?

Posted: 24 Jan 2011 02:56 PM PST

Personal Health: Long and Short of Calcium and Vitamin D

Posted: 24 Jan 2011 10:48 PM PST

The new daily recommendations for calcium and vitamin D, issued in November by the Institute of Medicine, have left many people wondering whether they are getting enough, or perhaps too much, in their diets and supplements.

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The institute’s expert committee, which included bone specialists, concluded that most people don’t need supplements of these critical nutrients and warned of serious health risks from the high doses some now take — including kidney stones and heart disease linked to calcium supplements, and the very falls and fractures that vitamin D is meant to protect against.

For bone health, vitamin D and calcium go hand in hand, because the vitamin must be present for calcium to be absorbed from the digestive tract. But who, if anyone, needs supplements — and how much? Can you get enough from foods naturally rich in these nutrients or fortified with them?

These are important questions, given the steady increase in life expectancy and the already epidemic levels of osteoporosis and fractures among older Americans, men and women alike. (Women are especially vulnerable, because estrogen loss at menopause can cause a precipitous decline in bone density.)

The answers depend on three things, not to mention which experts you happen to ask: the foods and drinks you regularly consume, your personal and family history of broken bones, and habits that influence bone health.

Dr. Robert P. Heaney, a bone specialist at Creighton University in Omaha, maintains that “at least one-third of all osteoporotic fractures have a nutritional basis.”

What you eat and drink, from childhood on, is critical to the amount of calcium in your bones. Dairy foods, especially milk, yogurt and cheese, are the primary sources of calcium in the American diet, and consumption of milk has been falling steadily for decades, especially in adolescence, when most bone development occurs. A British study concluded that frequent milk consumption before age 25 was an important determinant of bone strength among middle-aged and elderly women.

Other foods are not nearly as rich in absorbable calcium, or the amounts normally eaten do not come close to the calcium content of dairy products: 300 milligrams in a glass of milk, 400 milligrams in eight ounces of yogurt.

Sardines and canned salmon eaten with the bones are good sources, and almonds are a fair source if you eat enough of them. And calcium-fortified foods like orange juice, soy milk, breakfast cereals and tofu are now widely available.

Too Much of a Good Thing

But some other desirable foods are problematic, at least when it comes to calcium: you’d have to eat so much broccoli to approach the level in milk that it could be toxic to your thyroid gland. Other vegetables with calcium, like spinach, collards, kale and beans, contain oxalates that block calcium absorption.

For daily calcium intake, the institute now recommends 1,000 milligrams for children 4 to 8, women and men 19 to 50, and men 51 to 70; 1,300 milligrams for children 9 to 18; and 1,200 milligrams for women 51 and older and men 71 and older. The upper limit of safety, the institute said, is 2,000 milligrams a day for men and women over 51.

Thus, if you are a postmenopausal woman who typically consumes only one or two servings a day of dairy, you may be hard put to get 1,200 milligrams of calcium from the rest of your diet unless you take a supplement. Dr. Ethel Siris, director of the osteoporosis clinic at Columbia University Medical Center in New York, said such women could benefit from a supplement of calcium carbonate (600 milligrams a day) or calcium citrate (500 milligrams a day).

Be sure to read the product label carefully — a usual “serving” is two tablets. Calcium carbonate should be taken with meals to assure absorption, but calcium citrate can be taken at any time and may cause fewer digestive problems.

Most calcium supplements now also contain vitamin D (usually as cholecalciferol, or D3), supplying about 250 to 300 international units in two tablets. The Institute of Medicine recommends 600 units a day for everyone from age 1 to 70 and 800 units for men and women 71 and older, with a safe upper limit for everyone over the age of 9 of 4,000 units.

Vitamin D has one advantage over calcium: It is fat-soluble and can be stored in the body for later use. But getting enough of it can be tricky.

The body gets most of its vitamin D not from diet but from skin exposed to the ultraviolet B radiation in sunlight. Unprotected skin on the arms and legs may need about 15 minutes of sun exposure a day in spring, summer and fall to make enough of the vitamin.

Alas, this production is effectively blocked if you follow current advice to prevent skin cancer and wrinkles by always covering up or using ample amounts of sunscreen. Used properly, sunscreens with an SPF of 8 or higher completely block UVB radiation and prevent synthesis of vitamin D.

Also, people who are dark-skinned or housebound or who live in far northern latitudes may fail to make enough vitamin D. And as people age, their bodies are less able to convert the vitamin into the hormone that is its biologically active form.

Milk is fortified with vitamin D at a level of 400 units per quart, and some yogurts have it as well (check the label). Many breakfast cereals are also now fortified. The only naturally rich dietary sources are oily fish from the sea like salmon and mackerel, egg yolks, liver and fish liver oil.

Testing and Maintaining

An increasing number of physicians now routinely test vitamin D levels in the blood of their female patients, and if it is below 30 nanograms per milliliter, will suggest they take a supplement. The Institute of Medicine maintains that a level of 20 nanograms is adequate, but other experts say it should be higher to assure maximum calcium absorption and bone health.

In any event, unless you are a year-round sun worshiper, a daily supplement of calcium with D, or even a separate supplement of 1,000 units of D, is likely to keep you well below the institute’s upper safe limit. Based on current evidence, unless you have a severe deficiency requiring temporary megadoses to correct, there is no reason to go any higher.

At the same time, you’d be wise to get sufficient weight-bearing exercise and avoid several bone-robbing habits: smoking; eating a lot of salty foods; drinking more than two alcoholic drinks a day; consuming more than the caffeine equivalent of two cups of coffee a day (about 300 milligrams); and eating too little protein. As for soft drinks, Dr. Siris advises a daily limit of two 12-ounce cans, and she’d prefer that soda be only an occasional treat.

Really?: The Claim: Chia Seeds Can Help You Lose Weight.

Posted: 25 Jan 2011 12:17 PM PST

THE FACTS

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Chia Pets — those terra-cotta figurines that sprout fuzzy green hair — made the chia plant a household name. But chia has gained an entirely new reputation as a diet supplement.

Diet books and fitness gurus promote the plant’s seeds as an appetite suppressant, and health food stores and Web sites sell them by the pound. Chia seeds, which are native to Mexico and Guatemala and were cultivated by the Aztecs, are certainly chock-full of nutrition: a single serving, about an ounce (28 grams), delivers 4 grams of protein and 11 grams of fiber, which is supposedly the key to its weight-loss magic.

But there is little evidence that it lives up to that claim. In one study in 2009, a team of researchers randomly split 76 overweight and obese men and women into two groups. One group was given 25 grams of chia seeds twice a day, and the other was given a placebo. After 12 weeks, the scientists found no significant difference between the groups in appetite or weight loss.

Another team that reviewed the scientific evidence on chia came to a similar conclusion: There was no indication of “any effects” on weight loss. Nor did the researchers find much evidence supporting other health claims linked to the plant, like cardiovascular benefits. They noted that while chia is generally safe for consumption and a healthy addition to most diets, “further rigorous examination” of its effects as a supplement is needed.

THE BOTTOM LINE

There is little evidence that chia seeds or supplements promote weight loss.

ANAHAD O’CONNOR scitimes@nytimes.com

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Recipes for Health: Spicy Braised Sweet Potatoes

Posted: 24 Jan 2011 05:09 PM PST

This recipe is adapted from one in “The Glorious Foods of Greece,” by Diane Kochilas. The sweet potatoes, seasoned with lots of paprika and cayenne, are simmered with onions on top of the stove.

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Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

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2 tablespoons extra virgin olive oil

1 large red onion, halved and sliced thin across the grain

Salt

2 garlic cloves, minced

1 tablespoon plus 1 teaspoon sweet paprika

1/2 teaspoon cayenne (more to taste)

2 tablespoons tomato paste

4 large sweet potatoes (about 3 pounds), peeled and quartered or cut in sixths if fat

1/2 cup dry white wine

Water as needed

Note: Sweet potatoes may be labeled as yams. Look for dark orange flesh.

1. Heat the olive oil over medium heat in a large, heavy lidded skillet or Dutch oven. Add the onion and a generous pinch of salt. Cook, stirring, until tender, about 5 minutes. Add the garlic and cook, stirring, until fragrant, 30 seconds to a minute. Stir in the paprika, cayenne and tomato paste, and cook, stirring, until the tomato paste turns a rusty color, about one minute.

2. Add the sweet potatoes, and stir for about a minute until coated with the onion and spice mixture. Add the white wine, enough water to cover the sweet potatoes halfway (1 1/2 to 2 cups), and salt to taste. Bring to a boil, lower the heat to medium-low, cover and simmer 30 to 40 minutes until the potatoes are tender and the sauce thick. Taste and adjust salt.

If the sauce is still watery once the sweet potatoes are thoroughly cooked, do not adjust salt right away. Carefully remove the sweet potatoes to a platter using tongs. Turn up the heat, and reduce the sauce until thick.

Adjust salt, and pour the sauce over the sweet potatoes. Remove from the heat, and let stand for 5 to 10 minutes before serving.

Yield: Serves six.

Advance preparation: You can make this a day or two ahead of serving; reheat gently on top of the stove or in a medium oven.

Nutritional information per serving: 233 calories; 5 grams fat; 1 gram saturated fat; 0 milligrams cholesterol; 41 grams carbohydrates; 7 grams dietary fiber; 128 milligrams sodium (does not include salt to taste); 4 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Maple Pecan Sweet Potatoes

Posted: 25 Jan 2011 12:00 AM PST

Lime juice and maple syrup bring sweet, tangy flavors to these sweet potatoes. They taste even better the day after you make them.

Recipes for Health

Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

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3 large sweet potatoes (about 2 1/4 pounds), scrubbed

3 tablespoons maple syrup

3 tablespoons lime juice

3/4 cup water

1/4 cup chopped pecans

Note: Sweet potatoes may be labeled as yams. Look for dark orange flesh.

1. Preheat the oven to 350 degrees. Oil a baking dish large enough to accommodate the sweet potatoes in a single layer. Cut the sweet potatoes in half lengthwise, then into wedges if they’re fat. Combine the maple syrup, lime juice and water, and toss with the sweet potatoes in the baking dish until they are thoroughly coated. Cover the dish tightly with foil, and bake 45 minutes until tender.

2. Turn up the heat to 425 degrees. Uncover the dish, baste the sweet potatoes with the syrup in the baking dish and sprinkle on the pecans. Continue to bake uncovered until the sweet potatoes are thoroughly tender, about 15 minutes. Remove from the heat and serve, or allow to cool slightly before serving.

Yield: Serves four.

Advance preparation: You can make this a day ahead of serving. Reheat in a nonstick skillet until the sweet potatoes caramelize.

Nutritional information per serving: 285 calories; 5 grams fat; 0 grams saturated fat; 0 milligrams cholesterol; 57 grams carbohydrates; 9 grams dietary fiber; 140 milligrams sodium (does not include salt to taste); 5 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Sweet Potatoes: Nutrition Wrapped in Vivid Flavors

Posted: 24 Jan 2011 08:14 AM PST

My neighbor was going out of town last week, so he offered me a bag of sweet potatoes he’d bought. Rather than do what I usually do with sweet potatoes (bake them), I hit the books to learn what cooks in Asia, Mexico and the Mediterranean make with them.

Recipes for Health

Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

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A lot, it turns out.

By sweet potatoes, I mean the orange-fleshed tubers with brownish skin that growers and supermarkets often mislabel as “yams.” The two varieties at my local farmers’ market are jewel yams and the darker-skinned garnet yams, both sweet and moist.

In fact, actual yams have starchier, light yellow flesh and a rough, brown skin; they are native to Africa and Asia, and an important staple in the Caribbean and in parts of Africa. But they don’t have the impressive nutritional profile of real sweet potatoes.

Sweet potatoes have a low glycemic index (actual yams do not), and they’re an excellent source of vitamin A, in the form of beta carotene, and vitamin C. Sweet potatoes also provide vitamin B6, potassium, fiber, manganese, copper and iron. When you see the nutritional values accompanying this week’s recipes, you’ll find that sweet potatoes offer all of this at a relatively low caloric price.

Chili-Bathed Sweet Potatoes

Rick Bayless offers a wonderful recipe for sweet potatoes glazed with an ancho chili paste in “Rick Bayless’s Mexican Kitchen.” Instead of making the paste, I make a thinner glaze with canned chipotle and some of the adobo they’re packed in. The glaze makes a spicy contrast to the sweet potatoes.

2 garlic cloves, green shoots removed

Salt to taste

2 chipotle chilies in adobo, seeded

2 tablespoons adobo sauce from the chilies

1/2 teaspoon ground cinnamon

1/8 teaspoon freshly ground cloves (1 clove)

1/4 teaspoon freshly ground pepper

1/2 cup chicken broth or water

1 cup fresh orange juice

2 tablespoons honey

1 tablespoon finely chopped orange zest

2 tablespoons extra virgin olive oil

4 large sweet potatoes (about 3 pounds), scrubbed

Chopped cilantro for garnish (optional)

Note: Sweet potatoes may be labeled as yams. Look for dark orange flesh.

1. Preheat the oven to 350 degrees. Oil a 2-quart baking dish. Place the garlic, salt, chipotles and adobo sauce, cinnamon, cloves, pepper, broth, orange juice and honey in a blender. Blend until smooth. Strain into a large, wide bowl, and stir in the orange zest.

2. Cut the sweet potatoes in half lengthwise, then cut each half into 4-inch lengths. If the sweet potatoes are fat, cut the pieces in half lengthwise into wedges. Add to the bowl, and toss with the adobo mixture until coated. Transfer to the baking dish, then pour on the liquid from the bowl. Drizzle on the oil, and cover tightly with foil.

3. Bake 45 minutes in the preheated oven until tender. Raise the heat to 425 degrees, uncover the sweet potatoes and baste with the liquid in the pan. Continue to bake, uncovered, until the sweet potatoes are thoroughly tender and glazed and any sauce remaining in the pan is thick. Garnish with cilantro and serve.

Yield: Serves six.

Advance preparation: You can make this dish several hours ahead of serving and reheat in a medium oven. You can assemble the dish through Step 2 several hours before you bake it.

Nutritional information per serving: 269 calories; 5 grams fat; 1 gram saturated fat; 0 milligrams cholesterol; 52 grams carbohydrates; 7 grams dietary fiber; 262 milligrams sodium (does not include salt to taste); 4 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

F.D.A. Is Studying the Risk of Electroshock Devices

Posted: 26 Jan 2011 12:30 AM PST

Federal regulators are weighing whether to downgrade the risk classification of electroshock devices, reinforcing what many psychiatrists consider a deepening acceptance of electroshock in modern therapy.

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Dr. Charles H. Kellner with a patient before electroshock therapy at the Mount Sinai Medical Center in Manhattan.

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Richard Perry/The New York Times

Electroshock therapy “can really be life-saving” for the most severe form of depression, said Dr. Charles H. Kellner, with an electroshock device at the Mount Sinai Medical Center.

The procedure has had a resurgence in recent years. And an estimated 100,000 Americans — two-thirds of them women — undergo the treatment for major depression and other illnesses each year. Patients, anesthetized, receive a jolt of electricity from electrodes for several seconds, inducing a brain seizure and convulsions of up to a minute.

The American Psychiatric Association and other leading specialists are recommending that the Food and Drug Administration downgrade the devices to a medium-risk category from high risk, a move that will be reviewed by an agency advisory panel in Gaithersburg, Md., this week.

To some extent, the review has renewed the debate over electroshock. In 1990, F.D.A. staff proposed declaring the devices safe for major depression, but never took final action amid an uproar by opponents.

If the F.D.A. downgrades the devices to a medium-risk category, the equipment could be promoted and sold without new testing. Such a downgrade would place the devices in the same risk category as syringes and surgical drills.

If the F.D.A. leaves the devices in the high-risk category, however, manufacturers may, depending on the agency, have to withdraw them from the market.

The F.D.A. could require safety and effectiveness tests that have not previously been done. By regulating the devices, the F.D.A. is indirectly regulating the procedure.

The agency could make a formal decision later this year. The F.D.A. usually, but not always, follows recommendations of its advisory panels.

Supporters, including mainstream psychiatrists, say the treatment is much safer than it once was and could pass a rigorous F.D.A. review. But they assert that the device manufacturers cannot afford those tests.

“These tend to be mom-and-pop operations,” said Dr. Matthew V. Rudorfer, a psychiatrist and top specialist at the National Institute of Mental Health. “So I think the dilemma might be that undergoing new expensive clinical trials might be too expensive.”

Opponents, including some groups of former patients, maintain that electroshock can cause memory loss and brain damage that outweigh its short-term benefits.

“It’s all trial and error — it’s all experimental,” said Vera Hassner Sharav, president of the Alliance for Human Research Protection, an advocacy group in New York. “All the years it’s been controversial and there have not been clinical trials. Why not?”

Only two manufacturers, Somatics L.L.C. of Lake Bluff, Ill., and the Mecta Corporation of Lake Oswego, Ore., make the devices in the United States. The F.D.A. has asked them to submit all safety and effectiveness information as part of an agency review to be released before the advisory committee meeting beginning on Thursday.

Dr. Richard Abrams, who founded Somatics in 1983 with Dr. Conrad M. Swartz, and has written a textbook on electroshock, wrote the F.D.A. to say that none of his patients in more than 10,000 sessions over three decades had reported prolonged memory loss.

Dr. Swartz, who, like Dr. Abrams, is a retired psychiatry professor, said in an e-mail that any cognitive side effects from Somatics’ latest device “are distinctly less than they had been.” But he said Somatics could not afford an in-depth safety study that the F.D.A. could require if it left the devices in the high-risk category. That could cost millions of dollars.

“There is not nearly enough money in this industry to begin to pay for clinical trials that would be substantially larger than those already in the medical scientific literature,” Dr. Swartz wrote.

Mecta would not comment. “We always get negative press,” said a woman who answered the telephone at the company’s headquarters and did not give her name. “Too bad, because it’s good equipment.”

Somatics and Mecta each have annual revenue exceeding $1 million, according to Dun & Bradstreet. Dr. Swartz, asked about the revenue figure, said Somatics, like Mecta, was a private company. Their Web sites do not list prices or sales figures.

More than 1,000 hospitals and outpatient clinics in the United States use the two companies’ devices, according to Dr. Charles H. Kellner, a leading researcher, professor and chief of geriatric psychiatry at Mount Sinai School of Medicine in New York.

“It’s a treatment for the most severe form of depression,” Dr. Kellner said. “It can really be life-saving.”

The F.D.A. review was recommended by the Government Accountability Office in 2009 as part of an examination of the regulatory status of electroshock and about 20 other less controversial medical devices, like pacemaker electrodes and implanted blood access devices for hemodialysis. They were grandfathered into F.D.A. regulations when the agency was given more authority over medical devices in 1976.

The G.A.O. said those devices should go through the stringent approval process for high-risk devices or be reclassified as medium or low risk. A medium-risk designation could include adding controls like performance standards and patient registries.

The treatment costs $1,000 to $2,500 a session, and typically involves three sessions a week for two to four weeks, Dr. Kellner said. The fee includes the services of a psychiatrist and anesthesiologist. The equipment itself costs about $15,000 and may last years.

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Verbal Sparring Over Potential Senate Vote on Health Care

Posted: 23 Jan 2011 11:00 PM PST

WASHINGTON — Democrats and Republicans in the Senate waged a war of words on Sunday over efforts to force what would most likely be a symbolic vote on repealing the Obama administration’s health care law.

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The Senate minority leader, Mitch McConnell, says Republicans will use assorted means to fight the health care overhaul.

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Speaking on “Fox News Sunday,” the Senate Republican leader, Mitch McConnell of Kentucky, repeated his promise to bring the repeal measure up for a vote. He first made the pledge on Wednesday after the House voted 245 to 189 to repeal the law.

Senator Charles E. Schumer of New York, the third-ranking Democrat in the Senate, acknowledged on “Face the Nation” on CBS that Republicans could bring the issue to the floor as an amendment to another bill. But, he added, “we will require them to vote on the individual protections in the bill that are very popular and that even some of the new Republican House members have said they support.”

“So in the end,” Mr. Schumer said, “their repeal bill is going to be so full of holes it looks like Swiss cheese.”

Among the specific measures that Democrats could bring to a vote are those making prescription drugs less costly for the elderly and allowing people ages 21 to 26 to remain on their parents’ health care plans, he said.

Republicans control 47 seats in the Senate, well short of the 60 that are usually required to bring a measure to the floor. The majority leader, Senator Harry Reid of Nevada, has said a repeal bill will not come to the floor for a vote.

Asked on “Fox News Sunday” how he would maneuver such a bill to the Senate floor, Mr. McConnell maintained his position.

“I’m not going to discuss how we’ll do it from a parliamentary point of view here,” he said. “I assure you we’ll have a vote on repeal. If that does not pass, and I don’t think anyone is optimistic that it will, we intend to go after this health care bill in every way that we can.”

Republicans campaigned aggressively against the health care law during the midterm elections last year. While Democrats generally defended it, some have said they are open to reconsidering parts.

Senator Richard J. Durbin of Illinois, the No. 2 Democrat in the chamber, said on “Fox News Sunday” that he thought “revisiting the health care reform law is not unreasonable,” adding that he thought a provision requiring companies to issue a 1099 tax form to companies with which they do more than $600 in business “goes too far.”

Opponents of the provision have warned that it will create an avalanche of paperwork for small businesses and independent contractors.

“Let me be really bipartisan about this,” Mr. Durbin said. “I happen to agree with Senator McConnell that the revenue portion, the 1099 portion that he referred to, needs to be changed. It’s unreasonable.”

On Education: Positives With Roots In Tragedy On Campus

Posted: 24 Jan 2011 11:10 PM PST

In a 12-month period from 2003 to 2004, six New York University students committed suicide. These were very public suicides. “They were all jumping from buildings, as opposed to quietly hurting themselves in their rooms,” said Zoe Ragouzeos, the university’s director of counseling and wellness.

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Zoe Ragouzeos of New York University said that the pain from student suicides forced the university to take broad measures.

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(How public? On March 10, 2004, The New York Post published a photo of a student falling 24 stories, accompanied by the headline “Death Plunge No. 4.”)

“We painfully realized the effect on our community was so great we had to do something,” Ms. Ragouzeos said.

What N.Y.U. did over the next few years was overhaul and expand its services, creating what is considered one of the top campus mental health programs in the country.

There’s a pattern here. Some of the best university programs — at Virginia Tech, the Massachusetts Institute of Technology, Western Kentucky University — have been spurred by some of the worst tragedies.

So the question is: Will Pima Community College in Tucson — alma mater of Jared L. Loughner, the man charged with shooting to death six people this month — be the next to create something good from something so bad?

At N.Y.U., the mental health staff was expanded to 40 clinicians from 25. The university added a 24-hour hot line that now takes 9,000 calls a year (the phone number is on the back of every student ID card). The walk-in clinic for students in crisis is open 60 hours a week, compared with 15 hours in 2004. Crisis teams consisting of social workers with master’s degrees are dispatched round the clock, whether it’s to calm a student throwing a cellphone across the room in a 9 a.m. class or to arrange a hospitalization for someone talking about killing himself in a dormitory at 3 a.m.

The university used to refer students in need of psychotropic medication to private psychiatrists who can charge $300 an hour; now there are five in-house psychiatrists who charge a $30 co-pay per session.

N.Y.U. has also added a mental health first-aid training course. Employees who work in campus hot spots learn to identify mental illness symptoms as well as how to defuse a tense situation until help arrives. A hot spot is any place prone to frustrate, including the financial aid office (“Students really get stressed if they don’t get the money they need,” Ms. Ragouzeos said), the bursar’s office (“They stress if they can’t return to school because they owe money”) and the registrar’s office (“They’re not happy if they don’t get the right classes”).

While it’s likely that these improvements have contributed to the sharp drop in deaths in recent years, the suicides have not stopped. Asked when the last one occurred, Ms. Ragouzeos did not have to look it up. “Nov. 3, 2009,” she said. Asked how she remembered, she said, “You remember.”

When mental health advocates at the National Alliance on Mental Illness— as well as at the Jed Foundation and Active Minds, which both focus on college students — are asked to name universities with strong programs, the ones they single out have all learned the hard way.

M.I.T. expanded its program after a rash of suicides in the 1990s that culminated in April 2000 with the suspected suicide of Elizabeth Shin in a dormitory room fire that she may have set herself. In a lawsuit that was subsequently settled, her parents contended that professors ignored e-mails by Ms. Shin saying she wanted to kill herself and that the counseling service provided minimal help.

Western Kentucky added resources after the rape and murder of a freshman, Katie Autry, in her Poland Hall dormitory room in May 2003.

And after 32 people at Virginia Tech were shot to death in April 2007 by Seung-Hui Cho, a senior with a long history of mental illness, the university increased its mental health budget by 50 percent. According to a spokesman, Lawrence Hincker, the university, with 30,000 students, has spent an additional $1 million a year, including adding a second psychiatrist, two nurse practitioners and seven more counselors.

At Pima Community College, it appears that the campus police dealt responsibly with Jared L. Loughner in the year before his shooting rampage. According to a 51-page report released by the college, the police frequently responded to complaints about him from faculty members and students. And after Mr. Loughner was asked to leave the college last September, the police delivered a letter to his home explaining his suspension and then talked with his father.

Even though the report says college officials suspected that Mr. Loughner was seriously mentally ill, there is no indication that he received mental health care at Pima. That is because Pima, with 68,000 students, has no mental health care. Cindy Klinge, a college spokeswoman, said in an e-mail that after having “conducted countless interviews,” Pima was granting no more.

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Nanotechnology Gets Star Turn at Speech

Posted: 26 Jan 2011 08:28 AM PST

The presence of Amy Chyao, a 16-year-old from Richardson, Tex., in Michelle Obama’s box during the State of the Union speech puts a spotlight, as it were, on using nanotechnology and light to kill cancer.

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Working in the laboratory of Kenneth J. Balkus, Jr., a chemistry professor at the University of Texas at Dallas, Ms. Chyao, a high school junior, synthesized a nanoparticle that is essentially is a remotely triggered bomb that attacks cancer cells.

“That took the longest time,” Ms. Chao said in a telephone interview, referring to her efforts at synthesis. “I have so many failed batches on my bench.”

This type of cancer treatment, called photodynamic therapy, is already used for skin cancer, but Dr. Balkus wanted to find a way to treat tumors within the body. Infrared light can pass partway into the body, and shining it on Ms. Chyao’s nanoparticles sets off a chain of reactions, which release a reactive form of oxygen, which can then kill the cancer cells.

The nanoparticles were further customized with proteins, so they would dissolve in water, and with fluorescent gold nanoparticles, so they could be tracked within the body.

The research is promising, but far from ready, not even for clinical studies. Dr. Balkus said the next step would be to put the nanoparticles into cells and see if they work as designed.

“We’re at that stage,” he said. “It’s not exactly around the corner, but with the right level of effort and funding, we could certainly accelerate that.”

Three other young researchers joined Mrs. Obama for the speech: Brandon Ford, a high school junior from Philadelphia who belonged to a team that competed to develop advanced, fuel-efficient cars; Mikayla Nelson, a high school freshman from Billings, Mont., who was a member of a team that won a design competition for a solar car; and Diego Vasquez, a freshman at a community college in Phoenix who helped design a motorized chair for frail people.

Ms. Chyao, who won the top prize at the 2010 Intel International Science and Engineering Fair, said she wanted to pursue an academic career and become a chemistry professor like Dr. Balkus.

“She is one of those kids you would describe as brilliant,” Dr. Balkus said. “At some point in her future, she’ll be a star.”

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